Does clerkship order matter? Planning your 3rd year schedule

Tuesday, March 25, 2014

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No doubt that medical school schedules vary. Some begin "3rd year" during the "2nd year" and integrate the clinical experiences. Others start 2nd year with clinical rotations and also have a year of scholarly experience. And yet, many others (still) have the traditional 1910 "Flexnarian" 2+2 model of 2 preclinical years plus 2 clinical years. If you are presently immersed in basic science but are being asked to weigh in on your schedule for your clinical clerkships (or know someone who is), keep reading...

One intriguing study in JAMA in 2010;304 (11):1220-6 looked at clerkship order (the sequence of the clinical clerkships) exploring the notion that those completing the internal medicine clerkship might perform better on their subsequent clerkships than those who do not complete internal medicine first.Of note, this study was set at a single institution that had multiples campuses.

Their findings? Clerkship order mattered in some ways but not others. Specifically, first clerkship specialty was associated with subject exam scores, and to a lesser degree with overall clerkship grade.First clerkship specialty was not found to be associated with clinical grade or with USMLE Step 2 score.Students completing internal medicine first had higher mean overall clerkship grades than students who completed OB-GYN, psychiatry, or family medicine first.

The authors discuss "student lore" that the most desirable clerkship order starts with internal medicine. And, given that not everyone can do internal medicine first, they make some suggestions, including the incorporation of more "internal medicine-like" experiences early in the 3rd year. Of note, these experiences do tend to occur on pediatric clerkships as well, such as bedside learning, clinical decision making, continuity of care, exposure to a range of cultural and socioeconomic issues, and others.

Having heard the “word on the street” and hearing about this elegantly designed study from JAMA, there are still some other factors you might consider (to the extent that you have any choice or flexibility in your clinical clerkship sequence, even if what to go for in the lottery):

What field do you think you might want to go into? Though it is OKAY not to know!! Think about when during the year it might be good to be in that clerkship, for learning's sake, and to some extent with regard to how you will perform.Read on…

If you might want to go into pediatrics, for example, should you do that clerkship first, towards the middle of the year, or the end of the year? Let's ponder what might happen at the beginning of the year: you have tremendous energy, some nervousness, and you are also learning how to be a third year. In the middle of the year, you might still have some nervous energy, and use it for good. You will be somewhat more experienced, building your clinical reasoning skill set. And then towards the end of the year, some subset of students (though importantly, not all) lose energy. Some may feel they have already made their career choice and do not recognize the interdisciplinary nature of medicine and unfortunately miss out on some learning opportunities. But if you aren't going to lose that energy and can remain fully engaged in the learning and clinical care process at that point in the year, you will learn and could stand out, favorably so.

Perhaps not an option, but do you have any elective time in your 3rd year? If so, how will you make the best use of that time? Try out a subspecialty of interest? More exposure to your potential future field? Do something new? Get involved in a research project? A health policy or advocacy or medical education project? Travel for a global health experience? Some medical schools may not have any "built in" elective time in the 3rd year, but might still have options for carving out such time via creative rearranging/splitting/deferring. But if not an option at your school, please don't fret as there are plenty of experiences within the core clerkships, and of course, 4th year.

Even if you have little to no choice in arranging your schedule and even if you are completely undecided about your ultimate career path, remember that in any setting you can always learn one more thing and have one more experience that can potentially help some current or future patient or yours. That is, reflect and learn about people, about teamwork, about responsibility, about clinical decision making, about patient safety, about professionalism…and I could go on. Don't miss those everyday learning opportunities!

About the Expert

Terry Kind, MD, MPH, is Director of Pediatric Medical Student Education at Children's National Health System. For the last decade she has also served as a primary care pediatrician at the Children's National Health Center at Martin Luther King, Jr., Avenue, in Washington, DC.